The Scottish Public Services Ombudsman (SPSO) identified “significant and serious failings” after investigating two complaints about staff at Glasgow’s Queen Elizabeth University Hospital.
NHS Greater Glasgow and Clyde said while many aspects of the patient’s care were found to be appropriate, it recognised there had also been “clear failings”.
The unnamed woman’s late husband had a hip replacement at the hospital in June 2016 and was discharged with aspirin to reduce the risk of developing a blood clot.
Three weeks later he was readmitted with a suspected upper-gastrointestinal bleed, but suffered a sudden collapse and died from a cardiac arrest caused by a pulmonary embolism – a sudden blockage in a major artery.
He was found unconscious on the floor around an hour-and-a-half after he was last seen by nursing staff.
After taking independent advice, the SPSO found by discharging the man on aspirin alone “there was a failure to provide appropriate medication to reduce the risk of blood clots”.
The report notes there was “no completely effective way of preventing pulmonary embolism. However, providing appropriate medication could have reduced the risk”.
“We were unable to rule out the possibility that this failing may have contributed to (the man’s) death,” it added.
The SPSO found while medical care during the second admission was reasonable, nursing care was not.
A gap in the recording of observations was found while the difficult circumstances surrounding the death “could have been handled more sensitively by some staff”, the ombudsman said.
“I urge the board to reflect on how they communicate with families, particularly in sensitive and difficult situations such as the death of loved ones.”
A number of recommendations for the health board included a call for the widow to receive an apology for the failings identified.
A spokesman for the health board said: “The report outlines a number of aspects of this patient’s care which the ombudsman found to be appropriate.
“However, we recognise there were also some clear failings in the patient’s care and have written to the family to reiterate our condolences and to apologise for these failings.
“The ombudsman’s recommendations are being discussed by a multi-disciplinary team to identify how these can be quickly implemented and ensure that lessons learned in this case are shared with appropriate staff.”